Acute endogenous psychosis. Part 4

It is interesting to try to qualify acute psychosis not by using atomized, randomly intertwining symptoms, but by recognizing a regular shift of more holistic states. At the same time, impaired consciousness ceases to be a symptom only of mental confusion, and it is given a large place during “crazy flashes” and even with purely affective ones. As for the general assessment (from a clinical point of view) of the concept of acute psychoses of Ey, its weakest place is excessive schematization and psychologisation of mental diseases, an attempt to “break the deadlock” with the help of exclusively psychological and philosophical concepts. General pathological, biological basis of psychosis is bracketed, actually turning into a group of causes divorced from the nature of the phenomena they cause.

Ey is almost not concerned with the relationship of catatonic disorders with oneiric, individual acute psychosis or syndromes, where fear affect and nonsense prevail. The place of delirium, which seems to be dissolved in the concept of “amentia” (mental confusion), remains unclear. Having noted the weak points of the old approaches to the description of many acute psychosis, and in part using the new achievements of clinical psychiatry, Ey still bases his psychopathological synthesis on the materials of the clinical analysis of the past and only proposes his own scheme for them. Regarding the course of these acute psychoses, EU also allows a transition to schizophrenia or other chronic delusional states, although in most cases he considers the course of the disease favorable.

In German psychiatry, three main approaches to acute atypical psychosis were defined. Unlike French psychiatry, the answer to the question about the relationship of these psychosis to schizophrenia and manic-depressive psychosis often constitutes the main task. For one group of psychoses, although the atypical nature of their clinic is beyond doubt, it is still considered possible to classify them as either schizophrenia or manic-depressive psychosis. Loyalty to the dichotomous division of endogenous psychosis according to Krepelin and at the same time some deviation from it towards their typological understanding is expressed by these authors in that they admit the existence of mixed, or intermediate, psychosis.

Schneider (1957, 1967) divides the intermediate psychosis into 3 groups: in the first picture of the disease contains both schizophrenic and cyclothymic symptoms, in the second attacks of manic-depressive psychosis and schizophrenia alternate. The third group includes psychosis, the clinical picture of which is mainly schizophrenic, but at the “height” has a “manic-depressive tone” and vice versa. Schneider’s cycloid psychosis (see below) is atypical autochthonous psychosis related to manic-depressive psychosis.

Another major representative of classical German psychiatry — Mayer-Gross (1960) also attributed atypical psychosis mainly to schizophrenia and manic-depressive psychosis. Thus, in the manic-depressive psychosis, the author included a form with catatonic manifestations, a hereditary and familial form sui generis, and true mixed psychosis (with two pathological heredities). True, the author acknowledged the existence of forms that can not be attributed either to schizophrenia or to circular psychosis.

Questions of clinical description, classification of acute endogenous psychosis for many years have been the subject of a large German psychiatric school, the leading representatives of which are Kleist and Leonhard.

In Leonhard’s classification (1957), acute atypical psychosis is included in phase psychoses, in cycloid psychosis, in unsystematic schizophrenia. In phase psychoses described:

a) pure depression (suspicious depression, or depressive psychosis of a Kleist relationship);

b) pure euphoria (confabulatory euphoria, or acute expansive confabulous disease according to Kleist);

c) dreamy euphoria. Non-systematic schizophrenia includes affectively saturated paraphrenia, schizophasia, and periodic catatonia.

Of greatest interest is the group of cycloid psychoses, which, according to Leonhard, are bipolar positively flowing psychosis. This group includes the psychosis of fear — happiness, agitated-inhibited confusion, and hyperkinetic-akinetic psychosis. The psychosis of fear — happiness is characterized at one extreme by the presence of fear with distrust and ideas of relationship. The other pole (happiness) is determined by the experience of bliss with delusions of grandeur. There may also be pseudo-hallucinations, ecstatic stupor, delusions of physical influence, confabulation, incoherence of thoughts, etc.

In the case of another cycloid psychosis – “agitated inhibited confusion”, thinking disorder is a determining disorder according to Leonhard. When excited confusion there is incoherence of thoughts, which leads to the formation of abnormal ideas (false recognition, ideas of relationship). Auditory illusions are observed, and less often visual ones. With inhibited confusion

thinking is “still”, and this gives rise to ideas of attitudes, meanings, pronounced confusion, etc.

Finally, hyperkinetic-akinetic psychosis is characterized by the presence of “pure psychomotor arousal” or “inhibition”, independent of thinking disorder or affective disorders. In the hyperkinetic pole, expressive and reactive movements are observed. In the pole of akinesia, posture and facial expressions are noted, patients do not perform the simplest proposed movements, they offer resistance. Akinesis is often accompanied by confusion, and sometimes incoherent arousal with a frozen posture and facial expressions.

Ecstasy, ideas of the relationship can be observed, and sometimes the picture resembles mania or melancholy (most often this is observed when the motor psychosis increases or decreases).

Leonhard distinguishes clinical forms on the basis of a grouping of disorders around one core disorder: in one case of affective, in the other – thinking disorders, in the third – psychomotor. The remaining symptoms are more or less optional and most often “secondary”. It is interesting to note that neither the semiotics nor the role of the disturbance of consciousness is discussed in detail by the author. It is only mentioned that at the height of cycloid psychosis, disorders of consciousness can easily arise, and they can determine the scenic nature of false recognition. When describing periodic catatonia (in the group of non-systematic schizophrenia), the author does not include oneiroid disorders in its clinical manifestations.

In the literature, the nosological assessment of cycloid psychosis, proposed by Leonhard, meets many objections. Separate from psychoses, isolated from Kleist and Leonhard, are recognized by many psychiatrists as forms of acute “attacks” (motor psychosis, expansive confabulous disease).

The works of Kleist, Leonhard, and their numerous students allowed them to describe clinical contours in a new way and to describe in part the content of many acute psychoses. The work of this school, however, shows how important methodological principles are for the successful clinical description.

After identifying a definitive core disorder in these complex psychoses, the rest of the symptoms turned out to be very weakly associated with it. As a result of this approach, the oneyroid series of symptoms and other signs of disorder of consciousness fall out. Another weak point in the classification of these psychoses (reaching the level of nosological synthesis) is the recognition of phase as the defining and obligatory feature. How risky it can be seen from the results of the follow-up check 10 and more years after the first attack, 29 patients diagnosed with expansive confabulese (Giebner, 1961). Benign phasic course of the disease took only 14 patients. In 13 patients, a follow-up check established schizophrenia (paranoid or hebephrenic form), in 2 patients — organic psychosis (progressive paralysis, arteriosclerosis).

In German psychiatry, more and more supporters are finding a more extreme, purely typological assessment of acute anti-acute psychosis within a single psychosis.

So, Janzarik (1962), believing that with the current level of knowledge in psychiatry it is impossible to strive for the nosological distinction between endogenous psychosis, proposes to distinguish only psychopathological types. Within a single psychosis, he distinguishes between 4 types of dynamic psychopathological disorders that correspond to the clinical concepts of depression (“dynamic reduction”), mania (“dynamic expansion”), acute schizophrenic psychosis (“instability”), and schizophrenic defect (“emptying”). Conrad (1958), also a supporter of a single endogenous psychosis, divided it into 4 types depending on the severity:

1) the type of pure cyclothymic psychosis;

2) type of phase psychosis with delirium, a sense of change (schizoaffective psychosis, catatonia with “release of fantasy”, etc.);

3) the type that proceeds with seizures, but with residual effects in the states of remission, which makes it possible to speak of a fur coat, and not a phase;

4) the type of schizophrenic process in understanding Kraepelin early dementia.

The existence of typologically intermediate phase psychosis (between manic-depressive psychosis and schizophrenia), their interpretation from the standpoint of a single endogenous psychosis we find in recent years in the works of a number of leading German psychiatrists: Kranz (1969), Pauleikhoff (1969), Weitbrecht (1969), Petrilowitsch 1969, 1972). These authors did not specifically engage in the clinical study of individual forms of the psychoses in question, but even with a summary of the division of endogenous psychoses, they recognize a special clinic of acute atypical psychosis.

Portuguese psychiatrists have shown great interest in acute atypical psychosis for many years. Polonio (1954) called “cycloid psychosis and reactions” described acute psychosis, which divides into two groups: paranoid and incoherent. For both groups, the author considers as characteristic the occurrence on the background of “super clear” (“hyperlucidic”) or dimmed consciousness, an increase or decrease in mood and psychomotor activity. The beginning is usually sudden. The prognosis is favorable, personality changes do not occur. The author believes that these types of reaction are more likely than nosological units. According to the features of the clinical picture, Polonio distinguishes between: confabulous, hallucinosis, neurotrophy, paranoid expansive psychosis, paranoid attitudes towards oneself, paranoids of suggestion and influence, incoherent hyperkinetic and akinetic psychosis.

In addition to these “reactions,” Polonio described occasional schizophrenia. He referred those cases at which it was observed not less than three attacks divided by remissions to the last. He distinguishes paranoid, hebephrenic and catatonic forms (the latter is the most frequent). With all these forms, the pyknic constitution was more common, exogenous hazards before attacks. The most frequently observed were catatonic states of excitement and stupor, manic-disjointed, expansive delusions or delusions of persecution and hallucinosis. Often there is confusion, change of mood. The remaining symptoms are the same as for other (nuclear) forms of schizophrenia. Personality changes are not very pronounced and consist in the superficial nature of emotions and the absence of a clear sense of reality. The average duration of attacks in the absence of treatment – 7 months.

Barahona Fernandes (1959) identified a group of holodisfrenia, which includes several clinical types of psychosis: paranoid, hallucinatory, incoherent, motor, as well as twilight states and delirium. The author considers the main disorders of the global disorder of consciousness, attention and incoherence of thinking. There are disorders of sleep, instincts and affect, feelings of time, orientation. In the occurrence of these psychoses, constitutional, exogenous and psychogenic factors play a role. The course of the disease is acute, complete remission, without defect. Holodisfrenia differs from schizophrenia, according to the author, by the absence of a real discrepancy between behavior and frustrated functions. Nosologically, these psychoses are unclear, located between schizophrenia and manic-depressive psychosis.

As you can see, Polonio and Fernandes, adhering in terms of the clinical division of these psychoses of similar views with the Kleist and Leonhard schools, emphasize the special role of the disorder of consciousness. This brought them closer to the concept of Ey, which was reflected in the work of Goncalves (1961), an employee of their clinic.

When studying 45 patients (at the onset of the disease and at remote stages of the course), Goncalves came to the conclusion that the clinical picture of holodisphrenia is not always clear (as in the case of Leonhard’s cycloid psychosis), and he draws on the concept of disruption of Ey consciousness to explain this phenomenon. The author believes that with these psychosis, consciousness is almost always disturbed. The clinical picture may vary from attack to attack. Noting that the development of an attack goes through a regular change of syndromes, and recovery through a reverse change of states, Goncalves tries to concretize this situation. Acute delirium (delirium acutum), in his opinion, may be the final stage of these psychoses. In terms of nosology, Goncalves believes that a global disorder of mental functions distinguishes these psychoses from schizophrenia.

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